1144668682 NPI number — DR. CARMEN LAINE PUSTEJOVSKY AU.D.

Table of content: DR. CARMEN LAINE PUSTEJOVSKY AU.D. (NPI 1144668682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144668682 NPI number — DR. CARMEN LAINE PUSTEJOVSKY AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUSTEJOVSKY
Provider First Name:
CARMEN
Provider Middle Name:
LAINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144668682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 POOL RD
Provider Second Line Business Mailing Address:
102
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051-4266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-488-1637
Provider Business Mailing Address Fax Number:
817-488-2854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 POOL RD
Provider Second Line Business Practice Location Address:
102
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051-4266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-488-1637
Provider Business Practice Location Address Fax Number:
817-488-2854
Provider Enumeration Date:
06/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  80498 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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